STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
Symptoms at presentation are usually non-specific. The following symptoms should be investigated:
- fatigue, pallor or other symptoms of anaemia
- symptoms of serious infection, such as tachycardia, high fevers, rigors
- unresolving or unusual infection or fever
- abnormal bleeding or bruising
- sore gums or mouth ulcers
- unexplained bone pain
- unintentional weight loss
- unexplained fevers.
The following signs and symptoms require consultation as a medical emergency:
- sepsis
- symptomatic anaemia
- severe thrombocytopenia < 20 × 109/L
- major laboratory abnormalities
- very high white cell count (> 50 × 109/L) or signs of hyperviscosity, such as visual disturbance, confusion, severe headache or breathlessness
- spontaneous/uncontrolled bleeding
- coagulopathy.
People with AML may only have mild symptoms. It is not uncommon that a patient with few or no symptoms is diagnosed unexpectedly on a blood test conducted in primary care.
The presence of multiple signs and symptoms listed above is highly suggestive of AML, particularly in people with a history of an underlying pre-disposing haematological condition.
Presenting symptoms should be promptly and clinically triaged with a health professional.
If a serious blood disorder is suspected, a focused medical history and thorough clinical assessment should be undertaken.
Full blood count and film should be performed immediately.
If the patient is clinically unwell (presents with symptomatic anaemia, spontaneous bleeding, sepsis and has symptoms of hyperviscosity), immediate referral to an emergency facility is recommended without waiting for blood results.
Pathology laboratories should directly contact the referring doctor if leukaemia is suspected (e.g. unexplained pancytopenia or blasts detected in the blood). Results should be actively followed up by the general practitioner and acted upon on the same day. Morphologic evidence of APL, disseminated intravascular coagulation, severe thrombocytopenia and any organ dysfunction (renal/liver failure) should be considered a medical emergency.
Patients with a laboratory diagnosis of possible AML should be referred for immediate assessment by a haematologist at an appropriate facility.
The general practitioner should begin investigations immediately if AML is suspected.
Laboratory results should be actively followed up and progressed on the same day. It is the responsibility of both the referring doctor and pathology laboratory to identify the possibility of a diagnosis of AML and take appropriate action.
If the general practitioner confirms, or suspects a diagnosis of AML but cannot confirm it, they must refer the patient to see a specialist (haematologist) to make the diagnosis.
Haematologists must expedite assessments for referred patients. Healthcare providers should facilitate patients’ rapid access to acute leukaemia treatment services. All patients with suspected AML should be evaluated and cared for by a multidisciplinary team with experience in managing AML. Readily accessible contact referral details for leukaemia treatment centres should be available.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed AML should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
- Patients with sepsis, bleeding or severe symptoms should be regarded as a medical emergency and be referred immediately to an appropriate emergency facility without necessarily waiting for results of laboratory tests (same day). All emergency facilities should have existing arrangements to receive urgent haematological advice.
- Patients with suspected AML who present to an emergency department should be triaged as a medical emergency initially and discussed immediately with a clinical haematology service and/or transferred immediately to a specialist centre. This particularly applies to patients with suspected APL.
- Patients with a laboratory diagnosis of possible AML should be referred for an urgent assessment by a haematologist at an appropriate facility within 24 hours. A deferred assessment should only be done after a discussion between the referring doctor and the responsible haematologist.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- weight loss, which may require a nutritional assessment.
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
